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Violence and suicide assessment


scale in the psychiatric emergency
room
ARTICLE in COMPREHENSIVE PSYCHIATRY JANUARY 1990
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Violence and Suicide Risk Assessment


Psychiatric Emergency Room

in the

Robert Feinstein and Robert Flutchik


Structured clinical rating scales covering 10 areas related to suicide and violence were constructed
for use in a psychiatric emergency room (ER). Ninety-five ER patients were evaluated with the
scales, 50 of whom were discharged after the visit and 45 of whom were admitted to the inpatient
psychiatric wards of the hospital. The admitted patients were found to differ significantly from the
discharged patients on every one of the 10 scales. Scores on the scales were also found to predict
suicide precautions on the wards, harrassment of other patients as assessed from nursing notes,
and indicators of violence on the wards. The scales were also found to have high internal reliability
and high sensitivity and specificity. They appear to be helpful to clinicians in identifying patients in
need of hospitalization and may also serve as limited predictors of hospital functioning.
0 1990 by W. B. Saunders Company.

LMOST ALL PATIENTS admitted to inpatient psychiatric wards are


screened or evaluated in a psychiatric emergency room, general emergency
room (ER), or by other admitting services or clinicians. In most such settings, only a
small number of symptoms determine whether a patient is admitted or discharged.
Such factors as the patients ability to care for self, presence of family supports,
danger potential and treatment prognosis have been used, as well as duration of
illness, previous illnesses, ability to communicate, and personal appearance.2
Bengelsdorf et a1.3 developed a crisis triage rating system that is based on three
factors: dangerousness, support system, and motivation or ability to cooperate.
These investigators reported that scores based on such ratings were 97% concordant
with decisions made by a crisis team on the basis of clinical judgement. A
comparison of voluntary and two-physician (2-PC) committed patients at a state
hospital showed that only a small number of symptoms distinguished between the
two groups. These symptoms were antisocial acts, anger, belligerence, negativism,
agitation, and assaultive acts.4 Evidently, these symptoms are largely reflections of
dysfunctions of aggression.
In psychiatric ERs, violent ideation or acts are not uncommon. Based on a
random sample of 367 psychiatric ER patients, Skodal and Karasu found that 17%
of the patients were described as violent because of outwardly directed aggressive
ideation or behavior in their clinical presentations, and another 17% had suicidal
tendencies without aggression directed toward others. Approximately 5% of the
sample was both violent toward others and suicidal. It is of interest to note that of
the cases defined as violent in the ER, 70% had acted out violent impulses before
their ER visit. Of these repeaters approximately 70% denied any degree of
premeditation before acting, thus implying an important role of impulsivity in
violence. An earlier report on self-directed violence in ER patients indicated that
28% were suicidal.6

From the Department of Psychiatry, Albert Einstein College of Medicine/Monte$ore


Bronx, NY.
Address reprint requests to Robert Feinstein. M.D., 212 New Canaan Ave. Norwalk,
G 1990 by W. B. Saunders Company.
00~0-440x~90/3104-~005$03.00~0

Comprehensive

Psychiatry,

Vol. 3 1, NO. 4 (July/August),

1990: pp 337-343

Medical Center
CT 06850.

337

338

FEINSTEIN AND PLUTCHIK

With the general increase in crimes of violence over the past several decades, and
with complex legal issues raised by the Tarasoff case and others,8 there has been
increased concern with identifying violent individuals in the ER.9 Also of great
interest has been the question of how well psychiatrists can predict violent
behaviors, although most commentators on this issue have concluded that
prediction is poor. The problem is complex and far from being resolved.
The present study is concerned with three questions. First, what are the
differences on measures of violence and other indices, between ER patients who are
admitted to the inpatient service and those who are discharged? Second, to what
extent do measures of violence obtained in the ER correlate with indices of violence
for these same patients on the inpatient wards? Third, to what extent do measures of
suicidal behaviors obtained in the ER correlate with indices of suicidal behavior for
the same patient on the inpatient wards?
METHODS
Based on an extensive review of the literature, a Violence and Suicide Assessment form (VASA) was
constructed for the study. This form, shown in Table 1, covers 10 areas of interest. These are current
violent thoughts (during interview), recent violent behaviors (during the past several weeks), past history
of violent/antisocial/disruptive
behaviors (lifetime history), current suicidal thoughts, recent suicidal
behaviors, past history of suicidal behaviors, support systems, ability to cooperate, substance abuse, and
reactions during the interview. Within each area of interest there are a number of brief descriptions of
relevant behaviors varying in degree of severity or degree of psychopathology. For example, under the
area of current violent thoughts, the items and weights given to them are as follows: 4, expresses intense
wish to kill someone specific; 3, reveals command hallucinations to injure someone; 2, expresses
ambivalent wish to kill someOne specific; 1, expresses nonspecific feelings of rage or belligerence; and 0,
reveals no homicidal ideas. At the end of the rating scales, the clinician is asked to make a probability
estimate of the likelihood of suicidal ideation or behavior and a separate probability estimate of the
likelihood of violent ideation or behavior. The instructions given the clinicians are: Your probability
estimate (on a scale from 0 to 100) should refer to the next 3 weeks. In that period, do you expect that this
patient will show suicidal ideation or behavior and/or violent ideation or behavior?
This VASA form was used in the ER of a large municipal hospital by clinicians during a 4-month
period. During this time they evaluated 95 patients on the form as part of their usual screening,
evaluation, and treatment functions. The evaluations and decisions on a patient were made first. Then the
VASA form was completed. Patients in the study were selected from the psychiatric emergency service,
subject only to the need for voluntary cOnsent and being over the age of 1S years.
The design of the study was based on the idea that some of the ER patients would be hospitalized and
most would be discharged home or referred for further outpatient care. The final sample consisted of SO
discharged patients and 45 patients admitted to the inpatient wards.
Since the average length of stay of psychiatric patients at this hospital is approximately 3 weeks, all of
the admitted patients were discharged by the time the follow-up data collection period was instituted. For
each hospitalized patient, information was obtained on his (or her) number of seclusions, reasons for
seclusion, the number and nature of incident reports, the presence of suicide precautions, diagnoses,
discharge disposition, drugs used, and nursing notes relevant to suicidal or violent behavior. Based on this
information. several indices were constructed of violence-related or suicide-related ward behavior.

RESULTS

Table 2 presents the general demographic data for the patients, including sex
distribution, mean age, marital status, race, and diagnoses.
The two groups have approximately the same age and racial distribution, but the
inpatient group has relatively more single males. Inpatients also have a higher
frequency of multiple suicide attempts, more of a history of drug abuse, and more
signs of suicidality (gestures and ideation) at the time of admission. Twenty-three

Table 1. Violence

and Suicide Assessment

Scale

Current Violent Thoughts (during interview)


Expresses intense wish to kill someone specific.
4
Reveals command hallucinations to injure someone.
3
Expresses ambivalent wish to kill someone specific.
2
1 Expresses nonspecific feelings of rage and belligerence.
Reveals no homicidal ideas.
0
Recent Violent Behaviors (during the past several weeks)
Showed serious assaultive behavior (e.g., tried to strangle, stab, or shoot someone).
4
Beat up someone badly (e.g., broke bones or required hospitalization).
3
2
Slapped or pushed or punched someone (no serious outcomes).
1 Broke things in house or elsewhere.
Showed good control of his (her) behavior.
0
Past History of Violent/Antisocial/Disruptive Behaviors (lifetime history)
4
Has committed violent acts in the past (e.g., beaten up people).
4
Has been arrested for assaultive behavior.
3
Carries weapons (e.g., knife, gun, chain, razor, etc.).
Has access to weapons.
3
Has been arrested for automobile infractions.
2
Has a criminal record.
2
2
Chronic problems with authority (e.g., truancy, running away from home, family fights).
2
Has a history of impulsive or unpredictable behavior. (e.g., loses temper easily, overeats, sexual
promiscuity, etc.).
Frequent changes of living situation as a child.
2
Has no past history of violence.
0
Current Suicidal Thoughts (during interview)
Expresses intense wish to kill self and has made a plan.
4
Reveals psychotic or delusional ideation or hallucinations to kill or injure self.
4
3
Expresses intense wish to kill self but has made no plan.
2
Expresses ambivalent wish to kill self.
0
Reveals no suicidal ideas.
Recent Suicidal Behaviors (during the past several weeks)
4
Made a serious suicidal attempt (e.g., tried to kill self by gunshot, ingestion, hanging or jumping).
3
Made a suicidal gesture (e.g., superficially cut wrist or ingested two pills).
3
Made a specific suicide plan.
3
Attempt made with little chance of discovery by others.
2
Had no interest or hope for the future.
0
Has no suicidal plans or attempts.
Past History of Suicide (lifetime history)
4
Mother, father or sibling has committed suicide or made a suicide attempt.
3
Has (or had) a diagnosis of major affective disorder or psychosis.
3
Has made one or more previous suicide attempts.
2
Current attempt is an anniversary reaction.
2
Has a serious medical illness or disability.
0
Has no past history of suicidal ideas or attempts.
Support Systems/Stresses
3
No family, friends, social agency, or psychiatrist available.
2
Has tenuous connection with family, friends, social agency, or psychiatrist.
2
Has had many recent life stresses (e.g., job, family, children, health, etc.)
1 Has a family which is marginally willing or able to help.
0
Has a family strongly committed and able to help.
Ability to Cooperate
3
Refuses to cooperate with interview and treatment plan.
2
Unable to cooperate with interview and treatment plan.
1 Wants help but motivation is weak.
0
Actively seeks treatment: willing and able to cooperate.
Substance Abuse
3
Is intoxicated.
3
Is in withdrawal.
3
Is a compulsive long-term drug abuser (includes alcohol or other drugs).
2
Is an occasional drug abuser (alcohol or other drugs).
1 Recreational use of drugs.
0
No abuse of any drugs.
Reactions During Interview
4
Assaultive behavior against a person (or object) in the environment.
3
Challenges authority (e.g., curses, yells, screams).
2
Shows approach-avoidance behavior toward interviewer.
1 Shows motoric activity (e.g.. pacing, smoking, fidgeting, etc.).
1 Seems very impatient.
Calm, seated, responsive to questions.
0
m 1986 by Robert Feinstein and Robert Plutchik.

FEINSTEIN AND PLUTCHIK

340

Table 2. Demographic Information Comparing the ER Patients Who Were


Inpatients With Those Who Were Discharged from the ER

Admitted

Inpatients
(N = 45)

Outpatients
(N = 50)

Mean age (yr)

33.4

34.2

Male
Female

62%
38%

38%
62%

Single
Married
Divorced
Separated
Widowed

66%
14%
11%
9%
0%

51%
26%
9%
5%
9%

35%
23%
40%
2%

38%
28%
34%
0%

5%
9%
86%

0%
10%
90%

38%
7%
14%
41%

27%
2%
6%
27%

Brought by police

23%

8%

Major depression
Dysthymia
Schizophrenia spectrum
Substance abuse

25%
3%
42%
31%

20%
15%
30%
35%

Variables

White
Black
Hispanic
Other
More than one prior suicide attempt
One prior suicide attempt
No prior suicide attempt
History
Suicide
Suicide
Suicide

of substance abuse (yes)


attempt at admission (yes)
gesture at admission (yes)
ideation at admission (yes)

as

percent of the inpatients were brought to the ER by the police, while only 8% of <he
discharged patients were brought by police. In terms of diagnoses, the inpatients
had more schizophrenic spectrum illnesses (schizophrenia, atypical and reactive
psychoses, schizoaffective disorders) and less dysthmia. The prevalence of major
depression and substance abuse disorder in the two groups was approximately the
same.
The psychometric properties of the rating scale were then examined. The first
three items were all concerned with violence, current, recent, and past. The internal
reliability of these three items as measured by coefficient alpha is .68, a reasonable
level of reliability. The coefficient alpha internal reliability of the next three items
concerned with suicide, current, recent, and past is .73, also satisfactory. When the
entire group of 10 items is considered as a scale, the alpha internal reliability is .79.
It thus appears that there is a high degree of interrelation among the violence items,
the suicide items, and the social support and motivational items. A total score on this
scale thus reflects the fact that suicidality, violence, lack of social support, refusal to
cooperate, substance abuse, and current interactional styles are all related. The total
score may thus be conceptualized as a psychosocial distress index.

VIOLENCE/SUICIDE

RISK ASSESSMENT

IN THE ER

341

Table 3 presents a comparison of ER patients who were discharged with those


who were admitted to the inpatient wards. The admitted patients are significantly
more functionally impaired than the discharged patients on every variable. They are
more violent, more suicidal, less cooperative, more substance abusing, and with
fewer social supports. The clinicians rate them as having a significantly higher
probability of both suicide and violence, and they have a significantly greater history
of prior suicide attempts and violent episodes.
Following is a summary of the significant product-moment correlations obtained
in the study that describe short-term predictions. The presence of suicidal ideation
at the time of admission to the ER is highly correlated with suicide precautions
taken on the ward (+.63) and with the number of days on suicide precautions
(+ .32). The number of prior suicide attempts is highly correlated (+ .61) with the
harrassment of others on the wards (as judged from nursing notes), and is also
highly correlated with the risk of violence in the hospital (+ .60). The risk of violence
in the hospital as a composite score based on the sum of the following 10 items: total
number of seclusions, uncontrolled behavior, physical aggression against others,
loud noisy behavior, inappropriate social behavior, destructive toward objects,
verbal threats or abuse, violence toward staff, violence toward patients, and
harrassment of others. Information about these items was obtained directly from the
patients medical records. The risk of violence in the hospital is also highly
correlated with a history of substance abuse (+.63). Finally, it appears that the
suicide probability estimate is correlated with the violence probability estimate
( + S3).
Since the lo-item VASA scale appears to have high internal reliability, its
sensitivity and specificity were also determined. The ability of the total scale score to
Table 3. Comparison

of ER Patients With Those Admitted to the Inpatient


the Items of the VASA Scale

Service Using

Discharged Patients
(N = 50)

Admitted Patients
(N = 45)

Items

Mean

SD

Mean

SD

Current violent thoughts


Recent violent behavior
Past history of violence
Current suicidal thoughts
Recent suicidal behaviors
Past history of suicide
Support systems/stresses
Ability to cooperate
Substance abuse
Negative reactions during interview

.12
.38
1.36
.40
.44
.a8
1 .oo
.4a
.a2

.48
.92
2.83
.a1
1.03
1.61
1.18
.71
1.49

.a4
1.09
2.91
2.07
2.13
3.35
2.27
2.13
1.73

i .38
1.36
3.09
2.77
1.89
2.59
1.56
4.38
I .a2

3.34t
2.92t
2.52t
4.81$
5.33%
5.40$
4.433
2.50*
2.62*

.36

.92

1.84

2.50

3.75$

Total score
Suicide probability estimate
Violence probability estimate

6.24
20%
12%

6.71
17.3
14.8

19.38
52%
44%

9.26
30.5
30.6

7.84$
6.15$
6.154

lP < .05.
tP< .Ol.
SP< .OOl.

FEINSTEIN AND PLUTCHIK

342

discriminate between those ER patients who were admitted to the inpatient service
and those who were not was examined for different cutoff scores. As typically found,
when specificity (i.e., the ability to identify true negatives) increased, sensitivity
(e.g., the ability to identify true positives) decreased. The optimum cutoff score for
maximum sensitivity and specificity was found to be 11. A score of this value
produced a sensitivity and specificity of approximately 82%.
DISCUSSION

The focus of this study has been on the initial assessment of violence or suicide
risk in a psychiatric ER and the extent to which such assessments are able to predict
certain aspects of the subsequent course of hospitalization. It was found that
patients who are immediately hospitalized after an initial ER evaluation are
somewhat different from those who are discharged home. They tend to be younger,
contain a higher proportion of males, are more likely to be single, have a more
frequent history of substance abuse, are more likely to have made multiple suicide
attempts in the past, and are more likely to present with suicidal ideation or
gestures.
All patients were assessed using an expanded lo-item version of the Bengelsdorf
et al (1984) triage rating system. The results showed that the ER patients admitted
to the inpatient wards scored significantly higher on every one of the items as well as
on total score. They also scored higher on the frequency of both prior suicide
attempts and violent episodes. These findings clearly indicate that the VASA scale
significantly discriminates between admitted and discharged ER patients. As
further support of this point, the sensitivity and specificity were both found to be
quite high (82%) using a cutoff score of 11. It thus appears that the VASA scale
may be a useful tool for clinicians in ERs to guide the clinical interview.
The second key question of the study was to examine whether initial ER data have
any predictive value in describing aspects of the course of short-term inpatient
hospitalization. The results indicate that the number of prior suicide attempts is
highly correlated with the likelihood of violent behavior in the hospital (r = .60). A
history of substance abuse is also highly correlated with the likelihood of violent
behavior in the hospital within 3 or 4 weeks after admission (r = .63). It was also
found that three items of the VASA scale (lifetime history of suicide attempts, lack
of social support systems, and inability to cooperate with the interviewer) correlate
significantly with suicide risk in the hospital (r = .41) as estimated from nursing
notes. It thus appears that some degree of prediction of acting out aggressive
behavior is possible over relatively short time periods, using simple clinically
obtained measures. We thus believe that the rating scales described here have value
for the clinician to help in the identification of patients who need to be hospitalized,
and may also serve as limited predictors of some aspects of hospital functioning.
ACKNOWLEDGMENT
The authors would like to thank Janie Lynn Feldman for assistance in data collection.

REFERENCES
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VIOLENCE/SUICIDE

RISK ASSESSMENT

IN THE ER

343

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